- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,993.20 / $8,425.81 / $8,628.84
| Professional | | $7,993.20 | $8,425.81 | $8,628.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.22 / $8,628.84 / $8,628.84
| Professional | | $474.22 | $8,628.84 | $8,628.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.55 / $439.55 / $439.55
| Professional | | $439.55 | $439.55 | $439.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $670.00
| Professional | | $5.00 | $5.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.45 / $8,459.66 / $12,689.49
| Professional | | $2,800.45 | $8,459.66 | $12,689.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.03 / $159.11 / $711.12
| Professional | | $131.03 | $159.11 | $711.12 |